Hepatobiliary Pathology Research Articles

Overlap syndrome in Crohn’s disease

The diagnosis of inflammatory bowel diseases (IBD) in children can be challenging for pediatricians. Extra-intestinal manifestations, such as hepatobiliary pathology, often complicate the diagnosis of these conditions. Hepatobiliary pathology is often an extraintestinal manifestation of inflammatory bowel disease. Patients with combined liver pathology (autoimmune hepatitis and primary sclerosing cholangitis) and inflammatory bowel disease have a higher risk of resistance to treatment, the need for liver transplantation, and a worse prognosis for liver cirrhosis compared to those with isolated liver disease. The article presents a clinical case of the development of overlap syndrome (a combination of autoimmune hepatitis and primary sclerosing cholangitis) in Crohn’s disease in a 7-year-old patient.

Determination of prothrombin time by the Ovren method in recipients after liver transplantation from a donor diagnosed with brain death

Objective. To evaluate a new method for diagnosing the state of the hemostatic system in patients with hepatobiliary pathology who underwent liver transplantation from a donor diagnosed with brain death. Materials and Methods. A pilot prospective study was conducted involving 10 patients with liver cirrhosis of various etiologies who underwent liver transplantation from a donor diagnosed with brain death. Laboratory parameters of liver function were analyzed perioperatively, during the first 5 days, on the 10th and 14th day after surgery and before discharge or death. The correlation of the prothrombin time by Ovren with the prothrombin time by Quick and with the international normalization ratio was determined using the Spearman rank correlation coefficient. Values of p ˂0.05 were considered statistically significant. Results. The mean number of points on the scale for assessing the severity of liver failure (MELD) before surgery was 27.7 ± 6 (minimum – 15, maximum – 36), which corresponded to severe class C liver failure. The correlation between the value of prothrombin time according to Quick and according to Ovren, as well as between the values of the international normalized ratio and prothrombin time according to Ovren was statistically significantly negative: rs = –0.85315, p (two–sided test) = 0.00042 and rs = –0.90527, p (two–sided test) ˂0.05, respectively. The Ovren prothrombin time was 48% on the 5th day after surgery, after which the functions and reserves of coagulation normalized starting from the 10th day, which is conveniently assessed by an increase in this indicator to 74.5% and above. Conclusions. Determination of the prothrombin time by Ovren can improve the diagnosis of liver failure and monitoring of liver function recovery in patients after liver transplantation from a donor diagnosed with brain death.

Morphological characteristics of the stromal-parenchymatous component of the liver of fetal and newborn developed under the conditions of maternal hypertension disease

Background. Extragenital pathology of the mother can cause various changes in the body of the newborn, which in the future are the cause of violations in physical and mental development, and also causes an increase in somatic and infectious diseases in such children. Therefore, timely diagnosis of liver diseases in newborns and young children remains an urgent problem today. Purpose – the article is devoted to the study of the morphological features of the stromal-parenchymal component of the liver of fetuses and newborns that developed under conditions of maternal hypertension. Materials and Methods. Research was conducted on liver preparations of fetuses and newborns who died at the age of 37 weeks of gestation – the 1st day of postnatal life. All the studied material was divided into two groups. The control group (group K) included fetuses and newborns from healthy mothers (18 cases) who died due to acute disruption of umbilical-placental circulation and birth trauma. The comparison group (group C) consisted of 36 fetuses and newborns from mothers with stage II hypertension. The obtained micropreparations were stained with hematoxylin and eosin, picrofuchsin according to the van Gizon method, and according to the Mallory method. The parenchymal, stromal, and vascular components were calculated as a percentage, and then the stromal-parenchymal ratio was calculated. Results. The results we obtained during the conducted research indicated that the influence of chronic intrauterine hypoxia, which developed against the background of stage II hypertensive disease in the mother, leads to the development of destructive-dystrophic changes in the liver tissue of fetuses and newborns. Chronic intrauterine hypoxia with maternal arterial hypertension leads to parenchymal losses and has a pronounced stimulating effect on the stromal component of the liver, and this can lead to a significant decrease in the functional activity of the liver under the influence of certain triggers and increases the risk of developing liver failure and liver cirrhosis in the future. Conclusions. During our research, it was established that chronic intrauterine hypoxia, which develops against the background of stage II hypertensive disease in the mother, leads to the development of significant destructive-dystrophic changes in the liver tissue of fetuses and newborns. There is a decrease in the volume of the parenchyma due to the volume of hepatocytes and an increase in the volume of the stroma with vessels due to the volume of the portal tracts (11.2 ± 2.2% compared to the control – 3.4 ± 0.3%), the volume of the central veins (12.9 ± 1.3% compared to the control – 9.4 ± 0.4%), the volume of sinusoids (13.3 ± 1.1% compared to the control – 11.3 ± 0.8%). It was established that the morphological changes described by us in the liver of fetuses and newborns in the subsequent ontogenesis may become a prerequisite for the development of hepatobiliary system pathology in such children.

The effects of technical nuances of design and construction of laparoscopic instruments on the solution of the problems of surgical treatment of the hepatobiliary zone pathology

The effects of technical nuances of design and construction of laparoscopic instruments on the solution of the problems of surgical treatment of the hepatobiliary zone pathology

ULTRASOUND TECHNOLOGIES IN ALGORITHMS OF CHRONIC LIVER DISEASE MANAGEMENT

Aim. To improve the management algorithm of chronic hepatobiliary pathology by using ultrasound technologies to assess the structure of the liver. Materials and methods. The results of an anonymous electronic survey of 304 doctors using a tailored questionnaire and the authors' own experience of implementing quantitative ultrasound methods of liver assessment at the University Clinic of the Bogomolets National Medical University were analyzed. In accordance with the objective, an analysis of current international guidelines of relevant medical associations was performed. The study of the use of ultrasound diagnostics in the healthcare system of Ukraine was performed using data from open sources of the Ministry of Health of Ukraine and dashboards of the National Health Service of Ukraine (NHSU). Statistical analysis was performed using the MedStat program. The study was approved by the local ethics committee. Results. The availability of basic ultrasound diagnostics of hepatobiliary pathology is high and growing, while modern technologies for quantitative assessment of the liver structure are not sufficiently implemented in medical practice. An improved multilevel patient’s pathway with suspected steatotic liver disease is proposed. Conclusions. Significant limitations of the use of specialized liver examinations in medical practice may adversely affect the quality of medical care. Given the trends in the prevalence of chronic liver disease, the healthcare system needs additional technical equipment for healthcare facilities and focused continuing professional development activities for doctors to ensure the implementation of evidence-based management of chronic hepatobiliary pathology. An improved algorithm of interaction between doctors and the staged use of non-invasive diagnostic tests can help improve the medical care quality and the efficient use of human and financial resources of the healthcare system.

Pkd1l1-deficiency drives biliary atresia through ciliary dysfunction in biliary epithelial cells

Syndromic biliary atresia is a cholangiopathy characterized by fibro-obliterative changes in the extrahepatic bile duct (EHBD) and congenital malformations including laterality defects. The etiology remains elusive and faithful animal models are lacking. Genetic syndromes provide important clues regarding the pathogenic mechanisms underlying the disease. We investigated the role of the gene Pkd1l1 in the pathophysiology of syndromic biliary atresia. Constitutive and conditional Pkd1l1 knockout mice were generated to explore genetic pathology as a cause of syndromic biliary atresia. We investigated congenital malformations, EHBD and liver pathology, EHBD gene expression, and biliary epithelial cell turnover. Biliary drainage was functionally assessed with cholangiography. Histology and serum chemistries were assessed after DDC (3,5-diethoxycarbony l-1,4-dihydrocollidine) diet treatment and inhibition of the ciliary signaling effector GLI1. Pkd1l1-deficient mice exhibited congenital anomalies including malrotation and heterotaxy. Pkd1l1-deficient EHBDs were hypertrophic and fibrotic. Pkd1l1-deficient EHBDs were patent but displayed delayed biliary drainage. Pkd1l1-deficient livers exhibited ductular reaction and periportal fibrosis. After DDC treatment, Pkd1l1-deficient mice exhibited EHBD obstruction and advanced liver fibrosis. Pkd1l1-deficient mice had increased expression of fibrosis and extracellular matrix remodeling genes (Tgfα, Cdkn1a, Hb-egf, Fgfr3, Pdgfc, Mmp12, and Mmp15) and decreased expression of genes mediating ciliary signaling (Gli1,Gli2, Ptch1, and Ptch2). Primary cilia were reduced on biliary epithelial cells and altered expression of ciliogenesis genes occurred in Pkd1l1-deficient mice. Small molecule inhibition of the ciliary signaling effector GLI1 with Gant61 recapitulated Pkd1l1-deficiency. Pkd1l1 loss causes both laterality defects and fibro-proliferative EHBD transformation through disrupted ciliary signaling, phenocopying syndromic biliary atresia. Pkd1l1-deficient mice function as an authentic genetic model for study of the pathogenesis of biliary atresia. The syndromic form of biliary atresia is characterized by fibro-obliteration of extrahepatic bile ducts and is often accompanied by laterality defects. The etiology is unknown, but Pkd1l1 was identified as a potential genetic candidate for syndromic biliary atresia. We found that loss of the ciliary gene Pkd1l1 contributes to hepatobiliary pathology in biliary atresia, exhibited by bile duct hypertrophy, reduced biliary drainage, and liver fibrosis in Pkd1l1-deficient mice. Pkd1l1-deficient mice serve as a genetic model of biliary atresia and reveal ciliopathy as an etiology of biliary atresia. This model will help scientists uncover new therapeutic approaches for patients with biliary atresia, while pediatric hepatologists should validate the diagnostic utility of PKD1L1 variants.

Study of the stability of dental implants on the background of the hepatobiliary system pathology

Annotation. Today, dental implantation is one of the most important methods for restoring dental defects. This method allows restoration of tooth row defects without preparation of hard tooth tissues. Endoosseous dental implantation in patients with concomitant pathology requires special attention, among which pathology of the hepatobiliary system stands out, which has recently tended to increase. This is primarily due to the epidemiology of viral hepatitis, deterioration of the external environment, and complex social conditions of life. The purpose of our work was to investigate the stability of dental implants using the analysis of frequency-resonance indicators in patients with hepatobiliary system pathology. A study of the stability coefficient was conducted in 26 patients who had intraosseous dental implants installed. All patients were divided into 2 groups: the first – main (14 patients) – without pathology of the hepatobiliary system; the second – comparative (12 patients) - included patients who had disorders of the hepatobiliary system, which were established on the basis of the collected anamnesis and violations of biochemical indicators. There were equal numbers of men and women in each group. There were 8 (57.2%) women and 6 (42.8%) men in the first group, and 5 (41.7%) men and 7 (58.3%) women in the second group. For all patients, dental intraosseous implantation was performed in one or two zones of included defects. After the installation of dental intraosseous implants, the stability of the dental implant was determined using a frequency-resonance study. Similar studies were also conducted after the opening of the dental implants before the installation of the orthopedic structure after 6 months. The results. We found a significant difference in the coefficient of stability of dental implants in patients with hepatobiliary system pathology and without liver pathology (p<0.05). In the main research group, the following coefficients of stability of dental implants were obtained: immediately after the installation of dental implants intraoperatively, a study of indicators was carried out, which corresponded to the level of 70,41±2,97 points, and already after 6 months this indicator of the stability coefficient in±creased and was fixed at the level 75,41±2,59 points. In the patients of the second research group (comparison), immediately after the installation of dental implants, the stability coefficient was at the level of 42.56±3.53 points, and 6 months after the installation of dental implants – 44,39±3,26 points. Liver pathology negatively affects the coefficient of stability of dental implants and their osseointegration, worsening them by 1,7 times. With liver pathology, osteopenia is observed, which requires preoperative and postoperative hepatoprotective correction and osteotropic therapy.

Secreted and surface proteome and transcriptome of Opisthorchis felineus

IntroductionOpisthorchis felineus, Opisthorchis viverrini, and Clonorchis sinensis are the most medically important species of fish-borne zoonotic trematodes. O. felineus is endemic to the river plains of Western Siberia and Eastern Europe, and it is estimated that more than 1.6 million people could be infected with this parasite. Chronic opisthorchiasis may lead to significant gastrointestinal and hepatobiliary pathology. This study aimed to identify and characterize proteins from the secreted and tegumental proteomes of O. felineus. MethodsAdult flukes were collected from experimentally infected hamsters and cultured in vitro in serum-free media. We extracted proteins from different compartments of the O. felineus secretome, including (i) soluble excretory/secretory (ES) products; (ii) secreted 15K-extracellular vesicles (EVs); and (iii) tegument. ResultsWe also generated a transcriptome using long-read sequencing, and when this was combined with high-resolution mass spectrometry, sodium dodecyl sulfate–polyacrylamide gel electrophoresis (SDS-PAGE) separation, and protein digestion, we identified 686, 894, 389, 324, and 165 proteins from the ES, 15K-EV, and the three sequentially extracted tegument (TEG) protein fractions, respectively. We conducted in-depth gene ontology and protein family analyses on the identified proteins and discussed comparisons against similar proteome data sets acquired for the Southeast Asian liver fluke O. viverrini and the Chinese liver fluke C. sinensis. DiscussionThe information from this study will form a biologically relevant data set of O. felineus proteins that could be used to develop diagnostic and therapeutic tools to manage the human cost of O. felineus infection and its associated comorbidities.

The Lasting Effects of COVID-19 on the Progression of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD).

It is estimated that around 30% of thepopulation living in Western countries has metabolic dysfunction-associated steatotic liver disease (MASLD), a spectrum of pathology (not attributed to alcohol/substance intake) initiated by steatosis and progression toward inflammation and irreversible fibrosis metabolic dysfunction-associated steatohepatitis (MASH). With inflammation being a key component of the transition to MASH, it raises the question of whether the ongoing COVID-19 pandemic, which has notoriously induced hyperinflammatory states, may influence the progression of MASLD. Specifically, it remains unclear if the potential chronic sequelae of COVID-19 in patients who recovered from it may increase the predisposition for MASH. Since MASH maintains a high risk for hepatocellular carcinoma, liver failure, and the need for a liver transplant, the potential additive effects of COVID-19 could prove critical to study. Thus, the objective of this study was to conduct a literature review to examine if COVID-19 could have chronic sequelae that affect the progression of MASLD pathogenesis. It was hypothesized that severe cases of COVID-19 could induce systemic inflammation, metabolic changes, and lasting gut microbiome alterations that lead to inflammatory and fibrotic changes in the liver, similar to those seen in MASH. A scoping review of the literature was conducted utilizing the PubMed database. Studies that examined hepatobiliary pathology, gut microbiome, systemic inflammation, metabolic changes, drug-induced liver injury (DILI), and hypoxia seen in COVID-19 were included. Human studies of adult cohorts, animal models, and in vitro experiments were included. Genetic components of MASLD were not examined. Exclusion criteria also encompassed any studies not referencing the hepatobiliary, gastrointestinal tract, portal system, or systemic circulation. Findings indicated a frequent trend of elevated liver enzymes, mild steatosis, Kupffer cell hyperplasia, and hepatobiliary congestion. It was found that direct cytopathic effects on hepatocytes were unlikely, but the direct viral insult of cholangiocytes was a potential complication. High serum levels of IL-1, TNF-a, and MCP-1, in COVID-19 were found as potential risk factors for MASH development. Hypoxia, altered lipid metabolism, and iatrogenic DILI were also proposed as potential precipitators of MASH development. Notably, lasting changes in gut microbiome were also frequently observed and correlated closely with those seen in MASH.

Use of modern methods for diagnostics of diseases of the heptobiliary system

In modern clinical veterinary practice, in the overwhelming majority of cases, the diagnosis associated with pathologies of the hepatobiliary system is established on the basis of a combination of clinical, laboratory and instrumental data, which is a rather laborious and cost-intensive process, which makes it relevant to search for new methods with more relevant. Laboratory assessment of the hepatobiliary system has several goals, including: determining the presence of hepatobiliary pathology, determining the presence of liver disease, including primary or secondary hepatitis, determining the definitive type of liver disease, and monitoring response to therapy or disease progression. We have comprehensively analyzed existing studies in the field of using various methods for diagnosing pathologies of the hepatobiliary system, identifying the most promising approaches from the point of view of veterinary hepatology for their further possible introduction into industry practice. The search and processing of scientific publications was carried out according to the recommendations of H. Snyder [10] for writing review articles. An assessment is given to the positive and negative sides of each technique.Based on the analyzed literature, it can be concluded that, despite the knowledge of the issues of hepatology and the diagnosis of liver diseases, there are gaps and weaknesses in any diagnostic model. Thus, one potential diagnostic model that is promising but little studied is the use of clearance tests. Functional tests allow not only to diagnose and differentiate hepatopathologies, but also to visualize their course and liver recovery.Also, unlike statistical tests, clearance tests allow you to evaluate the work of the liver in dynamics.

Оцінка стану тканин пародонта у хворих із соматичною патологією

The purpose of the study was to investigate the influence of concomitant somatic pathology on periodontal tissues. Materials and methods. 104 patients, aged 28–46 years, with diseases of periodontal tissues, who had somatic pathology, were involved in the study. The examined persons were divided into groups: 35 persons (group 1) with pathology of the hepatobiliary system, 37 persons (group 2) with pathology of the gastrointestinal tract, and 32 persons (group 3) with pathology of the cardiovascular system. The comparison group included 30 people with periodontal tissue diseases without somatic pathology. To determine the depth and prevalence of the inflammatory process of the gums the Svrakov’s number indicator was used. Oral hygiene was assessed according to the Silness-Loe and Stallard indices. The papillary-marginal-alveolar index (C. Parma, 1960) was determined to assess the severity of gum inflammation. Bleeding gums were assessed by the gum's papilla bleeding index according to Muhllemann. Statistical processing of the research results was carried out with a computer program for variational and statistical analysis of medical and biological research data “GraphPad Prism 5”. Results and discussion. Patients with diseases of periodontal tissues against the background of somatic pathology had the highest percentage of chronic generalized periodontitis of the II degree, in contrast patients of the comparison group had the highest percentage of chronic generalized periodontitis of the initial – I degree. Svrakov's number in patients with periodontal disease against the background of somatic pathology significantly (р ˂0.05) exceeded the indicators of patients of the comparison group. At the same time, there is no significant difference between the results of groups 1, 2 and 3. The highest values of the indexes of Silness-Loe and Stallard were recorded in patients with the cardiovascular system pathology, which significantly (p<0.05) exceeded the data in the comparison group, but did not significantly differ from the results of patients with pathology of hepatobiliary system and gastrointestinal tract. The papillary-marginal-alveolar index data were the highest in patients with hepatobiliary system pathology (64.25 ± 8.19%), which significantly (p<0.05) exceeded the results of the comparison group and in individuals of groups 2 and 3. The highest indicator of the bleeding index is 1.98 ± 0.22 points in patients of the 1st group, which significantly exceeds the indicators in the group of people without somatic pathology and in the group of patients with pathology of gastrointestinal tract and cardiovascular system. Conclusion. The conducted studies show that the presence of somatic pathology contributes to the development of periodontal tissue diseases, and certainly aggravates their course, which is proven by the results of the index assessment

The role of liver transplant for intrahepatic cholangiocarcinoma: the UK NHSBT liver advisory group pilot programme

Aim: Liver transplantation (LT) offers a potential curative treatment for non-metastatic intrahepatic cholangiocarcinoma (iCCA) in patients with chronic liver disease who are not amenable to liver resection (LR). Recent evidence suggests that cirrhotic patients with “very early” iCCA (single tumour, ≤ 2 cm) might benefit the most from LT, with a 5-year survival as high as 73%. In view of these developments, NHS Blood and Transplant’s Liver Advisory Group (LAG) established a Fixed Term Working Group (FTWG) to determine whether iCCA in patients with background cirrhosis should be considered for LT in the United Kingdom. Methods: The FTWG included cholangiocarcinoma/LT patient representatives, experts in cholangiocarcinoma surgery/oncology, LT surgery, hepatology, hepatobiliary radiology, hepatobiliary pathology, nuclear medicine, and representation from various national hepatobiliary/oncology and transplant professional bodies. The objective was to make recommendations on appropriate indications, patient selection criteria, referral criteria, radiological assessment, transplant listing pathways, data management, and overall quality assurance. Results: The FTWG recommended LT for very early iCCA in cirrhotics, who are otherwise not suitable for LR. In this paper, we summarise the selection criteria, patient pathways, referral framework, pre-transplant assessment criteria, outcome measures, and dissemination strategy for implementing this new indication for LT in the UK. Conclusion: The introduction and evaluation of this pilot programme is an important breakthrough for iCCA patients in the UK, marking a significant stride in the field of transplant oncology. The results of this service evaluation will describe the role of LT in iCCA and guide future programmes to optimise patient selection, management, and outcomes.

United Kingdom criteria for liver transplantation in the setting of isolated unresectable colorectal liver metastases.

Studies have demonstrated that liver transplantation may be an effective treatment for isolated unresectable colorectal cancer liver metastases (CRCLM). Published data suggest that 5-year survival may be as high as 80%; however, recurrent disease is commonplace. Consequently, the Liver Transplantation for Unresectable Colorectal Liver Metastases Fixed Term Working Unit recommended to the NHS Blood and Transplant Liver Advisory Group that while CRCLM is an appropriate indication for transplantation, selection criteria should be conservative and that it should be undertaken within a clinical service evaluation programme. The aim of this work is to outline the proposed UK selection criteria and follow-up process for CRCLM transplantation. Consensus statement by colorectal cancer/liver transplantation patient representatives, experts in colorectal cancer surgery/oncology, liver transplantation surgery, hepatology, hepatobiliary radiology, hepatobiliary pathology and nuclear medicine. This study provides a comprehensive outline of the inclusion/exclusion criteria for referral in the UK. Furthermore, the referral framework is also explained. Pretransplant assessment criteria for listing/delisting are outlined. Finally, the oncology-specific outcome measures posttransplant are described. It is anticipated this service will begin in December 2022. A series of educational events for the referrers and transplant units will be arranged throughout 2023 to highlight CRCLM as a newly accepted UK indication for transplantation. A national audit will be undertaken to identify patients currently on treatment who meet the criteria for transplant. Data will be collected in a national registry and reviewed on an ongoing basis to confirm the safety of this treatment and to determine if the inclusion criteria require revision.

Serotonin levels in adolescents with obesity and non­alcoholic fatty liver disease

The prevalence of obesity has reached epidemic proportions not only among adults, but also in the pediatric population. Expectedly the number of obesity-associated diseases, including non­alcoholic fatty liver disease (NAFLD) etc., increases, too. The pathogenesis of these conditions has common links, some of them are well known, others are being investigated. The latter include hormones of the gastrointestinal tract. They are considered as a part of the body’s humoral regulation. These compounds regulate energy balance of a body, and insulin resistance. It is assumed they can affect obesity and NAFLD pathogenesis.
 Objective — to determine serotonin levels in adolescents with obesity and NAFLD.
 Materials and methods. An examination of 108 adolescents aged 12—17 years with obesity (55 boys and 53 girls) was carried out. The control group consisted of 32 healthy adolescents (18 boys and 14 girls). Depending on the hepatobiliary pathology all patients were divided into two groups: 1st group included 29 (26.9 %) adolescents with functional disorders of the biliary tract (FDBT), and 2nd group consisted of 79 patients (73.1 %) with NAFLD and FDBT.All patients underwent a comprehensive clinical and anamnestic examination, clinical and biochemical blood tests, including determination of the levels of γ-glutamyl transpeptidase (GGT), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (AP), total bilirubin and its fractions, triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), very low-density lipoprotein cholesterol (VLDL-C), atherogenic coefficient (AC) value. Levels of fasting glucose and immunoreactive insulin (IRI), HOMA-IR index, and blood serotonin level were also determined. An ultrasound examination of the abdominal cavity was performed.
 Results and discussion. According to the clinical and anamnestic data, there were no differences between the groups of adolescents with obesity, depending on the existing hepatobiliary pathology, except for a higher value of the WC/Height in patients with NAFLD and FDBT (p < 0.01). The results of laboratory investigations demonstrated that in patients with NAFLD and FDBT, compared to patients with FDBT, the following parameters were higher: fasting glucose level (p < 0.05), IRI (p < 0.01), the value of the HOMA-IR index and the frequency of its increase (p < 0.01), levels of ALT and AST activity (p < 0.05), the levels of triglycerides and VLDL-­C (p < 0.05). The level of serotonin was higher in the group of patients with NAFLD and FDBT compared to the control group (p < 0.015).
 Conclusions. Adolescents with obesity, accompanied by NAFLD and FDBT, had higher rates characterizing abdominal obesity, carbohydrate and lipid metabolism, liver enzyme activity compared to patients with FDBT. Serotonin levels were higher in the group of patients with NAFLD and FDBT compared to the control group.

Laparoscopic hepatectomy for the treatment of pyogenic liver abscess: A retrospective case-control study.

Percutaneous catheter drainage is the first-line treatment for pyogenic liver abscess (PLA). Some patients need hepatectomy because of underling hepatobiliary pathology or unresponsiveness to nonoperative treatment, the traditional method is open hepatectomy (OH). Laparoscopic hepatectomy (LH) for PLA is rarely reported. The purpose of this study is to describe our experience of LH for treating PLA and to compare LH with OH. The medical records of patients who underwent LH for treating PLA were retrospectively analyzed, and the results were compared with those of patients with OH. From January 2015 to December 2021, 61 patients with PLA underwent hepatectomy, and 28 patients who underwent LH (LH group) were compared with 33 patients who underwent OH (OH group). There were no significant differences in the basic data between the 2 groups. Two patients in the LH group were converted to open surgery due to hemorrhage and dense perihepatic adhesions, there was no significant difference between the 2 groups in the operation time (186.2 ± 85.6 vs. 175.9 ± 76.7 minutes, P = .239), Institut Mutualiste Montsouris classification, extent of hepatectomy and drainage tube removal time, however, the blood loss (200.0 ± 100.5 vs. 470.9 ± 120.1 mL, P = .003), numerical rating scale (5.2 ± 1.8 vs. 9.1 ± 1.6, P = .042), the time to resume oral diet (12.3 ± 6.5 vs. 24.6 ± 10.2 hours, P = .005), the ambulant time (20.2 ± 7.3 vs. 40.2 ± 10.8 hours, P = .010), incidence of postoperative complications (14.3% vs.33.3%, P = .002), comprehensive complication index (46.2 vs. 60.6, P = .013), postoperative hospital stay (8.5 ± 7.3 vs. 13.5 ± 10.2 days, P = .025) in the LH group was significantly less than that in the OH group. Wit experience laparoscopic surgeons, treating PLA by LH is safe and feasible and compares favorably with OH.

S2949 Case of Cholangiogram-Induced Acute Liver Injury Disease

Introduction: We present a female who had prolonged acute hepatocellular liver injury after undergoing a cholangiogram using Omnipaque contrast. About 10 cases of cholestatic liver injury have been reported after ERCP, however our case is unique being predominantly hepatocellular injury. Case Description/Methods: Initially presenting with abdominal pain then diagnosed with cholecystitis, she underwent cholecystectomy with cholangiogram. She subsequently underwent ERCP due to a retained stone and discharged home the next day without notable complications. She presented to the hospital two days later with pruritus. After ruling out infectious cause and further mechanical hepatobiliary pathology, she was discharged home due to improved symptoms with symptomatic management. Transaminases gradually resolved with close outpatient follow-up at two weeks and two months. Discussion: The exact mechanism remains unclear, liver injury due to idiosyncratic reaction from contrast was postulated. This is possibly due to local hepatic injury from the contrast agent in the biliary system. The contrast material being infused under high pressure, can have a toxic effect on the liver with disruption of canalicular plasma membranes. Systemic distribution of the contrast medium from the bile duct and the spreading of the agent extracellularly to the nearby tissues might be responsible for direct toxic liver injury. Awareness of this reaction is helpful in preventing unnecessary repeat ERCP to confirm bile duct clearance as well as liver biopsies. Prednisone may be considered if persistently elevated liver enzymes.Figure 1.: Title: Liver Function Tests during clinical course Caption: Patient's liver function test over the hospitalization, readmission, two-week outpatient follow-up, and two-month outpatient follow-up revealing fluctuating elevation in transaminases after cholangiogram performed on day of admission while total bilirubin remains within normal limits. Gradual resolution of elevated transaminases over two-week and two-month follow-up. ERCP occurred on hospital day 1. Legend: HD- Hospital day RD- Readmission day ALP- alkaline phosphatase AST- Aspartate transaminase ALT- Alanine Transaminase.

S1821 Rare Case of Recurrent Liver Abscess Caused by Choledocodoudenal Fistula in Ampullary Diverticulum

Introduction: Choledocodoudenal Fistula is a rare condition that may be caused by Choledocholithiasis, surgical or laparoscopic cholecystectomy, duodenal ulcer and tumor invasion. Choledocodoudenal fistula has no specific symptoms and may be accidentally discovered during upper GI endoscopy; but in some cases, it may lead to recurrent cholangitis and liver abscess. In this article, a case of recurrent liver abscess caused by Choledocodoudenal fistula in ampullary diverticulum is reported. Case Description/Methods: A 68-year-old male was admitted to outside facility because of abdominal pain and liver lesion on ultrasound. The abdominal CT showed large heterogeneous mass measuring more than 16*11 cm with single porta hepatis enlarged lymph node measuring about 2*1cm. Hepatocellular Carcinoma was suspected, but liver biopsy revealed active hepatitis with areas of necrosis and supportive inflammation. He was Referred to ALAhli Hospital for evaluation of liver abscess (Table). ERCP showed Tiny Ampullary orifice in large diverticulum (Figure). The injection of the contrast revealed a fistula at the apex of diverticulum with good drainage through it. In cases of liver abscess secondary to fistula complication, surgical or medical management may be needed. The liver abscess in this case study was treated medically. Discussion: A management strategy for CDF depends on correcting the underlying cause. As this condition is most commonly stone induced Endoscopic sphincterotomy is the gold standard for CBD stone extraction, however this approach has been found to be successful in only 12% of cases of large stone extraction, usually requiring additional therapies. Endoscopic papillary balloon dilation is an alternative approach to maintain the function of the sphincter and to reduce the morbidity associated with traditional endoscopic sphincterotomy. Currently, the approach of sphincterotomy followed by balloon dilation has provided the best outcomes. Patients with multiple abscesses should receive antibiotics for 4–6 weeks. Percutaneous drainage is the treatment of choice for liver abscesses. Operative drainage is indicated for patients with an identified intra-abdominal focus of infection and for those in whom percutaneous drainage is not feasible or has failed. Anatomic liver resection is rarely required and is withheld for cases of underlying surgical hepatobiliary pathology. In our patient we choose the medical treatment with antibiotics in combination with image-guided percutaneous drainage with excellent outcome.Figure 1.: Ampulla in large Diverticulum. Table 1. - Laboratory results of the patient upon admission to Al-Ahli Hospital WBC 7.8K/ul S. Albumin 2.1g/dl Sodium 133mEq/L HCT 50% SGPT 6mg/dl Potassium 3.7 mEq/L Hemoglobin 16.8% SGOT 15mg/dl Cholride 107mmol/l Platelets 173K/ul Bilirubin(T) 0.6mg/dl S. Creatinine 0.85mg/dl ESR 75mm/hour Bilirubin(D) 0.4mg/dl BUN 17mg/dl INR 1.3 ALK.PHOS 171 U/L CRP 190mg/l

Comparative Study of the Role of MRCP and USG in Patients with Pancreatic Duct and Biliary Duct Pathology

Background: Various imaging modalities like USG, CT, Invasive cholangiography has been used since long for the evaluation of the pathology of hepato-biliary-pancreatic duct. These techniques pose some limitations either due to bowel gas and obesity in USG, distal CBD calculus and isodense calculus (isodense to bile) in CT (also not used in patient with history of contrast allergy) and post-procedural complications (followed by invasive cholangiography like ERCP and PTC). MRCP is a non-invasive diagnostic technique for the direct visualization of the biliary ducts images similar to that produced in PTC (percutaneous trans-hepatic cholangiography) and ERCP. Also, the continuous expanding spectrum of therapeutic options, including radiological interventions (for palliative and curative) for the patients with biliary tree pathology requires the accurate assessment of the lesion visualized. Aims & objectives: Comparison of sensitivity, specificity and diagnostic accuracy between the MRCP/MRI and USG in patients with pancreatic and hepato-biliary pathology and it’s related complications. Materials & methods: The study was a retrospective, single institutional study done during the last two years (January 2018 – December 2019) at IGIMS, Patna, Bihar (A tertiary care hospital). Data was collected from the departmental record for USG findings, medical record for history and PACS (Picture archiving and communicating system) for MRCP findings. Hundred patients were included in our study. All the data were entered in the MS Excel sheet and were expressed as percentage and variables as required. Vassarstats software was used for the data analysis. Results: Benign lesions were common in the age range of 46-60 years (23%), followed by 31-45 years. Most of the malignant lesions were detected in the age range of 31-45 years of age group (13%). USG detected and MRCP detected lesions were benign in 63% and 62% of the cases and malignant in 34% and 35% of the cases respectively. There were overlapping findings present in most of the cases. Pancreatitis, cholecystitis and choledochal cysts were usually associated with biliary tree calculi. Overall sensitivity, specificity and diagnostic accuracy of MRI with MRCP sequence (97%, 85% and 92.75%) is greater than that of USG (92%, 80% and 85.5%). Conclusion: MRCP combined with other MRI sequences was superior to the USG in identifying benign and malignant pathology. However, ultrasound remains the primary investigating modality of choice. However, with use of recent advances of USG like harmonic imaging there is significant improvement in the lesion characterization. MRCP is the modality of choice of imaging investigation for the characterization of the lesion especially in obese patients or to choose the patients who are ideal candidate for the MRCP. Keywords: Hepato-biliary-pancreatic pathology, MRCP

Liver Abnormalities in Turner Syndrome: The Importance of Estrogen Replacement.

Turner syndrome is one of the most frequently reported sex chromosomal abnormalities, affecting approximately 40 in every 100 000 live female births. The underlying chromosomal alteration is the complete or partial loss of X chromosome or mosaicism. Because of primary ovarian insufficiency, the synthesis of estrogen hormones is compromised, and patients require hormone substitution. Apart from the phenotypical presentation (short stature, primary amenorrhea), the effects of ovarian insufficiency can affect diverse organ systems (such as cardiovascular, endocrine, and lymphatic systems). Hepatobiliary pathology can present on a broad spectrum: from mild asymptomatic hypertransaminasemia to marked architectural changes. Estrogen hormone replacement therapy in these patients can improve the perturbations of laboratory values and can attenuate the progression of hepatic structural changes. Moreover, providing sufficient estrogen replacement has numerous benefits for other conditions of the patients as well. Both the all-cause mortality and deaths from cardiovascular complications are greatly increased in Turner syndrome, and hormone replacement might contribute to the decreased incidence of these events. The diagnostics of Turner syndrome are outside the scope of our paper, and we briefly discuss the cardiovascular complications because many the liver involvement partially involves alterations of vascular origin. Though we sought to highlight the importance of proper hormone replacement therapy, we did not attempt to write a comprehensive recommendation for exact treatment protocols. We provided an overview of preferred therapeutic approaches, as the treatment should be tailored according to the individual patient’s needs.

A CASE OF ERDHEIM-CHESTER DISEASE IDENTIFIED SIX MONTHS AFTER LUNG TRANSPLANT

TYPE: Case Report TOPIC: Transplantation INTRODUCTION: Erdheim-Chester disease is a rare type of non-Langerhans histiocytosis that can manifest with bone pain, marked elevation of alkaline phosphatase, and osteosclerotic lesions of long bones. CASE PRESENTATION: A 37-year-old female, bilateral lung transplant recipient (10/2020) with a history of post-COVID-19 acute respiratory distress syndrome, complicated by acute cellular rejection, antibody-mediated rejection, and refractory gastroparesis, was found to have Erdheim-Chester disease in the work-up of infiltrative pattern of liver enzymes at 6-months after transplant. DISCUSSION: The early postoperative course was complicated as described above; during her most recent hospital admission, she had an isolated elevation of alkaline phosphatase (208 U/L) with no obvious gastrointestinal symptoms, excluding gastroesophageal reflux or other hepatobiliary pathology. Over the course of one week, her alkaline phosphatase increased to 928 U/L, and the patient described a new onset, mild and non-specific lower tibial pain. A gamma-glutamyl transferase was elevated, necessitating a skeletal work-up. A bone scan and lower extremity radiographs both showed subtle, patchy, intramedullary sclerosis and cortical thickening in the right lower extremity. Together, her bone pain, elevated alkaline phosphatase, and radiologic features were consistent with Erdheim-Chester disease. Although a bone biopsy was warranted, given her guarded prognosis, this intervention was not pursued. CONCLUSIONS: Erdheim-Chester disease generally requires careful observation for disease progression. Unfortunately, in a lung transplant recipient with worsening allograft function and repeated hospitalization, the prognosis is poor. DISCLOSURE: Nothing to declare. KEYWORD: Erdheim-Chester Disease